Form SSA-L9784 Retirement, Survivors and Disability Insurance: Earnings

Social Security Administration
Retirement, Survivors, and Disability Insurance
Return Address
Date:
Claim Number:

BENEFICIARY NAME
ADDRESS
CITY ST ZIP
We need updated information about your work to make sure that we pay you the right amount of
Social Security benefits.
What You Need To Do
Please complete the enclosed form to tell us about your work. Please return it as soon as
possible in the enclosed envelope. Thank you for taking the time to complete the form. We may
contact you again if we need more information.
If You Have Questions
If you have any questions, please:


Visit our website at www.socialsecurity.gov to find general information about Social
Security.



Call us toll-free at 1-800-772-1213 or call your local office at [phone]. We can answer
most questions over the phone. If you are deaf or hard of hearing, our toll-free TTY
number is 1-800-325-0778.



Write or visit any Social Security office. If you plan to visit an office, you may call
ahead to make an appointment. The office that serves your area is located at:
[FO ADDRESS]

Please have this letter with you if you call or visit an office. If you write, please include a copy
of the first page of this letter. It will help us answer your questions.

Acting Commissioner
of Social Security

Enclosures:
Earnings Estimate Form SSA-9784-SM
Envelope

Estimate Your Earnings for [year]


In [year], the full retirement age for people born in 1949 is age 66. If you were born on
the first day of the month, we consider you to have reached full retirement age in the
prior month. For example, if your birthday is November 1, we treat you as if you reached
full retirement age in October. This means that if you were born November 1, 1949, you
only have to report wages for January through September. Question 1 shows the month
you will reach full retirement age.



If you are paid wages, base your estimate on what you expect to earn before taxes or
other deductions for the whole year. Be sure to include bonuses, vacation pay, sick pay,
tips of $20 or more a month, and any contribution that you make from your salary to a tax
deferred savings plan.



Drop from your estimate any money you will get from your employer this year for work
you did last year or before. Also, do not include:
-

Social Security, railroad or civil service retirement, veterans, black lung, or public
assistance benefits
Pensions and other retirement payments which are not reported on your W-2 form
Investment income
Interest from savings accounts
Life insurance annuities and dividends
Gifts or inheritances
Gain (or loss) from the sale of capital assets
Rental income
Unemployment or worker’s compensation
Jury duty payments



If you are self-employed, base your estimate on what you think your net earnings will be
– just like on your tax return. If you become entitled to Social Security benefits before
[year]:
- Do not include in your estimate any Federal agricultural program payments you
expect in [year]; and
- Do not include self-employment income received in [year] from carry-over crops for
work you did before you became entitled to Social Security benefits.



If you get both wages and income from self-employment, add the two amounts together.
The total is your estimate.

Now, you are ready to answer the following questions about your earnings. Again, it is
important for us to hear from you.

Form Approved
OMB No. 0960-0369

Page 1

EARNINGS ESTIMATE

1. How much do you think you will have earned this year in wages before [month], the
month you are full retirement age in [year]?
Show your answer in the space below. Use dollar amounts only; round cents to the nearest
whole dollar.

$

,

,

2. How much do you think you will earn in self-employment in [year]?
If you are self-employed, we will reduce your estimated self-employment earnings to adjust
for the period you are full retirement age and over.
Show your net self-employment earnings for the whole year in the space below. Use dollar
amounts only; round cents to the nearest whole dollar.

$

,

,

Please go on to the next question

Page 2
Your Retirement Plans
To help us make sure that we understand your answers, we would like to know if you have
retired, or if you plan to retire this year.
3. Have you retired, or do you plan to retire in [year]?
If you retired, or plan to retire from your regular (full-time) employment in [year], answer
“YES” to this question even if you work or plan to work part-time.
Show an “X” in the box next to your answer.

NO, I have not retired and I am not going to retire this year.
YES, I have retired, or plan to retire this year.
If you answered “yes”, please show your retirement date in the space below.

/
Month /

/
Day /

Year

Your Signature
I declare under penalty of perjury that I have examined all the information on this form, and it is
true and correct to the best of my knowledge.
_______________________________
Signature

_______________
Date

Also, please give us a telephone number where we can reach you during the day. We may
contact you directly if we need more information to process this form.
__________________________________
Daytime Telephone Number

For SSA Use ONLY
Ext.

WB1 WB2 WB3

Page 3
Privacy Act Statement
Retirement, Survivors, and Disability Insurance
Sections 203(h)(3), (4), and 205(a) of the Social Security Act, as amended, authorize us to
collect the information requested on this form. We will use the information to ensure that we are
paying you correctly. The information you provide is voluntary. However, failure to provide us
with the requested information could prevent us from making an accurate and timely decision on
your benefit amount.
We rarely use the information provided on this form for any purpose other than for the reasons
stated above. However, we may use it for the administration and integrity of the Social Security
programs. We may also disclose the information provided on this form in accordance with
approved routine uses of the Privacy Act, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to
the Government Accountability Office, General Services Administration, National Archives
and Records Administration, and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at
the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notices
entitled, Earnings Recording and Self-Employment Income Record, 60-0059, Claims Folder
System, 60-0089, and Master Beneficiary Record, 60-0090. These notices, additional
information regarding this form, and information regarding our programs and systems, are
available on-line at www.socialsecurity.gov or at your local Social Security Office.

Page 4
PAPERWORK REDUCTION ACT STATEMENT
Paperwork Reduction Act Statement – This information collection meets the requirements of
44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do
not need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 10 minutes to read the instructions, gather
the facts, and answer the questions. Send only comments on our time estimate above to: SSA,
6401 Security Blvd., Baltimore, MD 21235-0001.